Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Paget's disease of the nipple with underlying occult invasive carcinoma detected by magnetic resonance imaging and second-look ultrasound: Case report

INTRODUCTION

Paget's disease of the nipple (PDN) is a rare and often misdiagnosed condition characterized by the infiltration of adenocarcinoma cells into the nipple epidermis. It poses substantial diagnostic and therapeutic challenges due to its similarity to benign dermatological conditions and its association with in situ or invasive carcinoma.

CASE PRESENTATION

This report details the case of a 47-year-old woman with persistent nipple itching, rash, and occasional bloody discharge. No abnormalities were seen on the mammogram and ultrasound scans; punch biopsy was performed to confirm PDN. A small lesion missed by other imaging methods was detected via breast magnetic resonance imaging (MRI). A second-look ultrasound with needle localization enabled precise surgery. The pathology report after breast-conserving surgery (BCS) revealed invasive ductal carcinoma with no metastasis in the sentinel lymph node biopsy.

DISCUSSION

PDN often mimics benign skin conditions, leading to delayed diagnosis. Furthermore, timely identification is crucial as PDN is frequently associated with underlying breast malignancies. Additional imaging, such as breast MRI, is essential for comprehensive evaluation, as it can reveal hidden lesions previously undetected by conventional mammography and ultrasound. A second-look ultrasound guided needle placement for tumor localization, enhancing surgical precision, aesthetics, and reducing patient harm. Surgical management, including mastectomy, BCS with radiotherapy, and oncoplastic surgery, offers suitable options without affecting recurrence or survival in selected patients.

CONCLUSION

This case emphasizes the importance of employing additional imaging tools, such as breast MRI and second-look ultrasound for the early detection and surgical management of PDN.

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

The Use of MRI to Detect Malignancy in a Patient Presenting With Unilateral Bloody Nipple Discharge

Nipple discharge presents as either physiological, which is green, white, or yellow, or is considered pathological, which is typically unilateral, spontaneous, and bloody. Bloody nipple discharge (BND) can be due to underlying malignancy or premalignant lesions. Mammogram (MMG), ultrasound (US), MRI, and ductography are all used to evaluate BND, but different modalities offer greater value in the diagnostic process. Here, we present a case that demonstrates the ability of MRI to detect abnormalities not seen on MMG and US in the setting of BND due to underlying malignancy. The use of MRI earlier in the diagnostic process allows for the use of breast-conserving measures and decreases the possibility of metastasis. This would result in less of a need for more aggressive treatments.